Automatic Exchange of Information Entity Self-Certification Form

Automatic Exchange of Information Entity Self-Certification Form

Entity Self-Certification Form This self-certification form is collected to comply with existing and any future legislation enacted by any jurisdiction that provides for or is intended to secure the exchange of information (including, without limitation, under US FATCA and related Intergovernmental Agreements ( IGA ), the OECD Common Reporting Standard for Automatic Exchange of Financial Account Information ( CRS ) including the EU Directive 2011/16/EU on Administrative Cooperation in the field of Taxation, as amended ( EU DAC 2 ), or any other jurisdiction's legislation which is similar in effect to any of the above, any official interpretations or guidance thereof, or any law or regulations implementing an intergovernmental approach thereto, or any agreements made pursuant to the implementation of the foregoing, in each case as enacted, made, amended or replaced from time to time. US FATCA, CRS, EU DAC 2, applicable laws, regulations and/or guidance notes, are together referred to as the Automatic Exchange of Information ( AEOI ) regimes 1. Note that definitions may differ between AEOI regimes. Please seek professional advice when completing this form. Type directly into this form and return a signed copy. All Entities must complete Sections 1, 2 and 3. Section 4 should be completed only where instructed to do so. Please refer to instructions throughout this form and additional instructions/definitions in the Appendix (http://www.citcoforms.com/grp/escapp.pdf). 1. Entity Identification Legal Name of Entity/Branch 2 Jurisdiction of organization/incorporation Registered address Do not use a P.O. box or in-care-of address (other than a registered address) Mailing address If different from above Address City / Town State / Province Country Address City / Town State / Province Country Postal Code Postal Code 1 For further information on the Automatic Exchange of Information, refer to: CRS: http://www.oecd.org/tax/automatic-exchange/common-reporting-standard FATCA: https://www.irs.gov/businesses/corporations/foreign-account-tax-compliance-act-fatca EU DAC 2: http://ec.europa.eu/taxation_customs/taxation/tax_cooperation/mutual_assistance/direct_tax_directive/index_en.htm For accounts in Irish FIs, refer to : http://www.revenue.ie/en/companies-and-charities/international-tax/aeoi/what-is-aeoi.aspx 2 For Citco use only: C&T: Entity ViewPoint Number: CB: Account Number: GRP-Ent.SC D08D06M18B 2/11

2. Country of Tax Residence and related Taxpayer Identification Number Complete the Entity s place of Tax Residence/Residencies and the associated Tax Identification Number ( TIN ) 3 or functional equivalent for each place of Tax Residence indicated in the table below. 4 1. Country of Tax Residence Tax Residence Or if the Entity is tax resident in a country that generally issues TINs, explain why the Entity does not have a TIN or functional equivalent 2. Country of Tax Residence Or if the Entity is tax resident in a country that generally issues TINs, explain why the Entity does not have a TIN or functional equivalent ADDITIONAL REQUIREMENTS FOR US PERSON When the Entity is a US Person, an IRS form W-9 must be completed and attached. 3 Overview of the Tax Identification Numbers domestic rules: http://www.oecd.org/tax/automatic-exchange/crs-implementation-and-assistance/tax-identification-numbers/ 4 If you are completing this form on behalf of a branch, the country of tax residence of the head office of the legal entity should be declared in this section, not the country where the branch is located. GRP-Ent.SC D08D06M18B 3/11

ADDITIONAL REQUIREMENTS FOR NON-US FOREIGN FINANCIAL INSTITUTIONS ( FFIs ) Non-US Entities that are FFIs for FATCA must complete the below declaration. GLOBAL INTERMEDIARY IDENTIFICATION NUMBER ( GIIN ) DECLARATION 1 The non-us Entity 5 has obtained a GIIN for FATCA purposes - - - The non-us Entity is a Sponsored Investment Entity FFI with its own GIIN 2 The non-us Financial Institution is unable to provide a GIIN Name of the Sponsoring Entity: Indicate the reason: Sponsored FFI that does not require a GIIN, as it has no US reportable accounts and is resident in a Model 1 IGA jurisdiction: 6 - - - Name of the Sponsoring Entity: 7 Sponsored Closely Held Investment Entity GIIN of the Sponsoring Entity: - - - Name of the Sponsoring Entity: 7 Trustee-Documented Trust GIIN of the Trustee: - - - Name of the Trustee 8 It applied for a GIIN and will provide its GIIN within 90 days. It is an Exempt Beneficial Owner. It is another type of Certified Deemed Compliant Financial Institution ( CDCFI ). Please specify type of CDCFI: It is a Non-Participating Foreign Financial Institution. 9 Other, specify: (Must be a classification or exception not covered above and prescribed by the US FATCA Regulations and/or an applicable IGA.) 5 If you are completing this form on behalf of a branch of a legal entity provide the GIIN of the branch. 6 As of Jan 1 st 2017, sponsored investment entities are required to obtain their own GIIN, unless a Model 1 IGA exception applies at the time of furnishing this form, Such exemption may allow the sponsored entity to refrain from obtaining its own GIIN until no later than 90 days after a US account is identified. 7 For Citco use only: C&T: Sponsoring Entity ViewPoint Number 8 For Citco use only: C&T: Trustee ViewPoint Number 9 Can only apply to FI s in non-iga jurisdictions and for IGA jurisdictions if published on IRS list after a procedure of notification of significant noncompliance. GRP-Ent.SC D08D06M18B 4/11

ENTITY SELF-CERTIFICATION FORM 3. Entity Classification Section 3 must be completed by all Entities, including those resident in the US and UK. Select at least one of the below classification: Financial Institutions: select options A, B or C Non-Financial Entities: select options D, E, F, G, H or I Proceed to page 7 FINANCIAL INSTITUTIONS (US AND NON-US) Select option A, B or C A. Certain options require a second selection as instructed. This is to account for potential different classifications under separate AEOI regimes. Investment Entity Select one of a), b) or c) a) An Investment Entity resident in the United States or other NonParticipating CRS Jurisdiction and managed by another Financial Institution Refer to the list of Participating CRS Jurisdictions http://www.oecd.org/tax/transparency/aeoi-commitments.pdf For CRS purposes, provide details of the Entity s Controlling Persons in Section 4. 10 b) An Investment Entity that meets the below criteria: 50% or more of its gross income is attributable to the relevant 11 financial activities, or if the Investment Entity is managed by another Financial Institution, from investing, reinvesting or trading in Financial Assets, during the shorter of: the three-year period ending on 31 December of the year preceding the year in which the determination is made; or the period during which the Entity has been in existence c) An Investment Entity (i.e. for FATCA) that does not meet the criteria in b) above For CRS purposes, one of Non-Financial Entities options (D to G) must be completed, and if the Entity is qualified as a Passive NFE under G, provide Controlling Persons details in 12 Section 4. 10 For Citco use only: CRS Classification = Passive NFE 11 Relevant activities: conducts as a business one or more of the following activities or operations for or on behalf of a customer: i. trading in money market instruments; foreign exchange; exchange, interest rate and index instruments; transferable securities; or commodity futures trading; ii. individual and collective portfolio management; or iii. otherwise investing, administering, or managing Financial Assets or money on behalf of other persons. 12 For Citco use only: CRS Classification = Passive or Active NFE per selection GRP-Ent.SC D08D06M18B 5/11

ENTITY SELF-CERTIFICATION FORM B. Depository Institution, Custodial Institution, Specified Insurance Company Refer to the Appendix for definitions. C. Holding Company or Treasury Centre Applicable for FATCA only and to Entities resident in non-iga countries or, in very limited circumstances, to Entities residing in the following IGA countries: Malta, Ireland, Netherlands and UK. Refer to the definition of Holding Company and Treasury Center in the Appendix for more detail. In addition, for CRS purposes, one of the other options (Financial Institutions A to B or Non-Financial Entities D to G) must be completed, and if the Entity is qualified as a Passive NFE under G, 13 provide Controlling Persons details in Section 4. NON-FINANCIAL ENTITIES (US AND NON-US) Select option D, E, F, G, H or I For Non-Financial Entities that are unsure whether they are categorized as Active or Passive, refer to the Appendix. For the purposes of this section the term Non-Financial Entity as defined in CRS and EU DAC2 includes the term NonFinancial Foreign Entity as used in FATCA. D. Active Non-Financial Entity A corporation the stock of which is regularly traded on an established securities market, or a related corporation thereof. Name of established securities market: If the Entity is a Related Entity of a regularly traded corporation, provide the name of the regularly traded corporation: E. Active Non-Financial Entity A Government Entity, Central Bank or International Organization. F. Active Non-Financial Entity Other than options D or E. Please specify qualifying criteria (further details are available in the Appendix definition of Active Non-Financial Entity ): G. Passive Non-Financial Entity Provide details of the Entity s Controlling Persons in Section 4. H. Direct reporting NonFinancial Foreign Entity GIIN: 14 - - - Provide details of the Entity s Controlling Persons in Section 4. 14 13 For Citco use only: CRS Classification = Per selection 14 For Citco use only: CRS Classification = Per selection GRP-Ent.SC D08D06M18B 6/11

I. Sponsored Direct reporting Non-Financial Foreign Entity GIIN 15 : - - - Name of the Sponsoring Entity 16: Provide details of the Entity s Controlling Persons in Section 4. 14 4. Controlling Persons This section should only be completed if the classification selected in Section 3 directs the Entity to provide Controlling Person details. If directed to provide Controlling Person information, failure to complete Section 4 will result in the selfcertification being considered invalid 17. A Controlling Person is any natural person that meets any of the following tests, in the order below: 18 For companies and partnerships, Controlling Person means the natural person(s) that have a direct or indirect controlling ownership interest or voting rights (typically on the basis of a certain percentage, e.g. 10% or more) in the Entity. If no natural person(s) exercises control through ownership or voting rights per the above, the Controlling Person(s) of the Entity will be the natural person(s) who exercises control of the Entity through other means. Where no natural person(s) is/are identified as exercising control of the Entity through ownership interests or through other means above, the Controlling Person is deemed to be the natural person who holds the position of senior managing official. For trusts and other similar legal arrangements (e.g. foundations), Controlling Person means the natural persons being settlor, the trustee(s), the protector (if any), the beneficiaries or classes of beneficiaries, and any other natural person exercising ultimate effective control over the trust or similar legal arrangement. U.S. Controlling Persons When the Controlling Person is a US citizen/us passport holder and/or resident in the US for tax purposes (a green card holder or resident under the substantial presence test), an IRS form W-9 must be completed and attached. 19 If the Controlling Person is no longer a US citizen, a certificate of loss of nationality and a copy of the foreign passport must be provided. US Controlling Persons of US entities do not need to provide a W9 or US TIN. 15 As of 1.1.2017 a Sponsored Direct Reporting NFFE is required to have its own GIIN and can no longer use the GIIN of a sponsoring entity. 16 For Citco use only: C&T: Sponsoring Entity ViewPoint Number 17 For accounts in Cayman FIs, Investment Entities in Non-Participating CRS jurisdictions managed by another Financial Institution are not required to list any controlling persons if 1. You are a widely-held, regulated Collective Investment Vehicle (CIV) established as a trust and not required to identify your beneficial owners for AML/KYC purposes; 2. A pension fund established as a trust and not required to identify your beneficial owners for AML/KYC purposes, or 3. Your controlling ownership interest is held by a company listed on a stock exchange and subject to disclosure requirements (or you are a majority owned subsidiary of such a company). 18 These tests are cascading, with each to be used where the previous test has been applied and has not identified a Controlling Person. 19 If you have selected any of 3A (a), 3A (c), 3C, 3H, or 3I in the Entity Classification Section, US Controlling Persons do not need to provide a W-9 form or US TIN. GRP-Ent.SC D08D06M18B 7/11

Provide the information of each individual Controlling Person in the form below. Note that all fields have to be completed for the Controlling Person(s). CONTROLLING PERSON 1 Full Name 20 Address Full residence address Place of birth Date of birth (DD/MM/YYYY) City / Town State / Province Country Postal Code Type of Controlling Person Where controlling by virtue of ownership, please list percentage ownership: % 1. Country of Tax Residence Tax Residence Or if the individual is tax resident in a country that generally issues TINs, explain why the individual does not have a TIN or functional equivalent. 2. Country of Tax Residence Or if the individual is tax resident in a country that generally issues TINs, explain why the individual does not have a TIN or functional equivalent. 20 For Citco use only: C&T CP1 Entity ViewPoint Number: GRP-Ent.SC D08D06M18B 8/11

CONTROLLING PERSON 2 Full Name 21 Address Full residence address Place of birth Date of birth (DD/MM/YYYY) City / Town State / Province Country Postal Code Type of Controlling Person Where controlling by virtue of ownership, please list percentage ownership: % 1. Country of Tax Residence Tax Residence Or if the individual is tax resident in a country that generally issues TINs, explain why the individual does not have a TIN or functional equivalent. 2. Country of Tax Residence Or if the individual is tax resident in a country that generally issues TINs, explain why the individual does not have a TIN or functional equivalent. If there are more than 2 Controlling Persons, click on the following link to download a template: www.citcoforms.com/grp/escacpt1.pdf 21 For Citco use only: C&T CP2 Entity ViewPoint Number: GRP-Ent.SC D08D06M18B 9/11

5. Declaration and Signature I/We declare (as an authorized signatory of the Entity) that the information provided in this form is, to the best of my/our knowledge and belief, accurate and complete. I/We understand that the recipient is responsible for processing the information contained in this form (including personal data relating to the Controlling Persons). I/We warrant that any personal data provided by me/us to the recipient has been processed in accordance with the applicable data protection legislation and that, to the extent necessary, I/we have obtained the valid consent of the data subjects (Controlling Persons) to provide such personal data to the recipient for the purposes of this self-certification form. I/we have informed the data subjects (Controlling Persons) of their right to access the information that relates to them and which is reported to the relevant tax authorities and of their right to rectify this information. I/We undertake to advise the recipient promptly and provide an updated self-certification form within 30 days where any change in circumstances occurs which causes any of the information contained in this form to be inaccurate or incomplete. In case where the form is prepared on behalf of a model 1 IGA sponsored investment entity without its own GIIN as at 1.1.2017 and the applicable model 1 IGA allows for such exception we undertake to obtain a GIIN within 90 days of a US reportable account being identified and to communicate the replacement GIIN immediately to the recipient. I/We understand that I/we am/are required to reply to each information request sent to the Entity by the recipient and that failure to do so may have a negative impact on the reporting of information relating to the Entity and/or its Controlling Persons, such as potentially reporting to the wrong foreign tax authority. Where legally obliged to do so, I/we hereby consent to the recipient sharing this information with the relevant tax authorities pursuant to international agreements and domestic laws under the AEOI regimes. I/We understand that the recipient and/or the tax authorities may exchange this information, along with other information such as account balances or value at year-end, and where relevant, certain payments made with respect to the account during the calendar year, with tax authorities in other jurisdictions. I/We expressly acknowledge, agree and allow the Citco Group of Companies (Citco) 22 to store the information contained in this form on a centralised electronic database at secure sites possibly located outside the tax residence jurisdiction(s) of the Entity or its Controlling Person(s), and in respect of which I/we agree that: the information contained in this form may be made available to employees of Citco and any of its Affiliates (whether or not outside the tax residence jurisdiction(s) of the Entity or its Controlling Person); Citco or any other of its Affiliates (whether or not outside the tax residence jurisdiction(s) of the Entity or its Controlling Person) shall be entitled to use the information contained in this form to enable classification under any law, regulatory or other governmental enactment (e.g. foreign tax compliance purposes) and to carry out any necessary registration and compliance as prescribed by such law, regulations or governmental enactment; and this may imply a transfer of information to jurisdictions where the level of data protection may not be as high as within the tax residence jurisdiction(s) of the Entity or its Controlling Person. 22 The Citco Group Limited is the indirect parent of a network of independent companies. The Citco Group Limited provides no client services. Such services are provided solely by the independent companies within the Citco group of companies (hereinafter, the Citco group of companies ) in their respective geographic areas. The Citco Group Limited and the Citco group of companies are legally distinct and separate entities. They are not, and nothing contained herein shall be construed to place these entities in the relationship of agents, partners or joint venturers. Neither The Citco Group Limited nor any individual company within the Citco group of companies has any authority (actual, apparent, implied or otherwise) to obligate or bind The Citco Group Limited in any manner whatsoever. GRP-Ent.SC D08D06M18B 10/11

For further information regarding Citco s privacy policy, refer to: https://citco.com/footer/privacy-policy/ I certify that I am authorised to sign for the Entity in respect of all the account(s) to which this form relates. (See Appendix for list of positions that are typically authorized to sign for various types of structures.) Complete Information Print name of signer Date (DD/MM/YYYY) Position/ Title Sign Here Authorized Signature Complete Information Print name of signer Date (DD/MM/YYYY) Position/ Title Sign Here Authorized Signature The Citco Group Limited, May 2018 GRP-Ent.SC D08D06M18B 11/11